Discoid Meniscus

An Ultrastructural Study With Transmission

Electron Microscopy
Ozgur Ahmet Atay,*† MD, Murat Pekmezci,† MD, Mahmut Nedim Doral,† MD,
‡ † §
Mustafa Fevzi Sargon, MD, Mehmet Ayvaz, MD, and Darren L. Johnson, MD
† ‡
From the Department of Orthopedics & Traumatology and Department of Anatomy,
§
Hacettepe University School of Medicine, Ankara, Turkey, and the Department of Orthopedics
& Traumatology, Kentucky University School of Medicine, Lexington, Kentucky

Background: The ultrastructure of the normal menisci has been thoroughly investigated and found to correlate with meniscal
tears. Although discoid menisci are accepted to have the same composition as their normal counterparts, to our knowledge, no
study in the literature has investigated this issue.
Purpose: To investigate the ultrastructure of the discoid menisci and compare it with nondiscoid menisci.
Study Design: Descriptive laboratory study.
Methods: Meniscal biopsies were taken from 12 patients who were operated for meniscus tear and diagnosed with discoid
meniscus and from 6 patients who were operated for meniscal tear and did not have a diagnosis of discoid meniscus. The sam-
ples were examined with transmission electron microscopy.
Results: The study group demonstrated a decrease in the number of collagen fibers compared with the control group. Also, the
homogeneous course of the collagen fibers observed in the control group was replaced by a heterogeneous course in the study
group.
Conclusion: The ultrastructure of the discoid meniscus is different from the normal menisci.
Clinical Relevance: This difference may contribute to the vulnerability of the discoid meniscus to tears.
Keywords: discoid menisci; transmission electron microscopy; ultrastructure; meniscal tears

The discoid-shaped meniscus in humans is a morphologic
anomaly of the normal meniscus and was described as early
as 1889.16 It is a frequent finding in the Asian population,
with an incidence of about 20%, whereas in whites, it occurs
in less than 0.5% of the population.11 It has been shown that
discoid lateral meniscus is associated with an increased inci-
dence of either lateral or medial meniscus tears, ranging
between 38% and 88%, and the usual treatment is partial
meniscectomy.4,5,7,10-13 It is thought that the tears in discoid
menisci are attributable to abnormal shape and thickness
resulting in increased stress to the meniscal tissue.14
Because the relationship between arrangement of collagen
fibrils and meniscal tears is known, we thought that the
composition of the discoid menisci might be another impor-
tant factor predisposing to tears. Therefore, we performed a
study to investigate the ultrastructure of discoid-shaped
menisci and compare it with normal counterparts.
MATERIALS AND METHODS

*Address correspondence to Ozgur Ahmet Atay, MD, Department of
Orthopedics & Traumatology, Hacettepe University School of Medicine,
06100 Ankara, Turkey (e-mail: oaatay@hacettepe.edu.tr).
No potential conflict of interest declared.
The American Journal of Sports Medicine, Vol. 35, No. 3
DOI: 10.1177/0363546506294678
© 2007 American Orthopaedic Society for Sports Medicine
Patients who were operated between September 2003 and
December 2005 with the diagnosis of discoid menisci were
included in the study. The study group was composed of
patients who were operated with the diagnosis of lateral dis-
coid meniscus and an associated lateral meniscal tear (Table
1). The control group was composed of patients who under-
went knee arthroscopy because of knee pain associated with

475
476 Atay et al The American Journal of Sports Medicine

TABLE 1
Demographic Details and Pathological
Findings of the Study Group

Sex Age Discoid Typea Type of Meniscal Tear

Female 5 Complete Horizontal cleavage +

longitudinal
Female 9 Incomplete Radial
Female 13 Incomplete Longitudinal
Female 23 Incomplete Radial
Female 24 Incomplete Radial + horizontal
cleavage
Male 27 Incomplete Radial
Female 28 Complete Horizontal cleavage
Male 33 Incomplete Radial + horizontal
cleavage
Male 42 Incomplete Radial
Female 46 Complete Horizontal cleavage +
radial
Male 48 Complete Horizontal cleavage + Figure 1. A horizontal cleavage tear observed in a patient
longitudinal with complete type discoid meniscus.
Male 50 Incomplete Horizontal cleavage
a
Discoid meniscus classification according to Watanabe classification.

lateral meniscal injury. All patients had preoperative mag-

netic resonance imaging demonstrating discoid meniscus,
meniscal tear, or both. Standard surgical arthroscopy was
performed in each patient. The arthroscope was intro-
duced through the anterolateral portal, and the instru-
ments were introduced through 1 or 2 additional portals.
The meniscectomy was performed with a basket suction
pump, and the remaining rim was resected with a shaver.
We tried to preserve the meniscus as much as possible,
particularly the peripheral rim, which contributes to joint
stability and load transmission. Only the portions that
were related to symptoms of the patients were addressed.
The torn menisci were partially resected, and 2 biopsy
samples were taken from the parts that were free of tears.
The same guidelines were followed for both the study
group and the control group. The biopsy specimens were Figure 2. A vertical longitudinal tear observed in a patient
fixed in 2.5% glutaraldehyde for 24 hours, washed in phos- with incomplete type discoid meniscus.
phate buffer (pH 7.4), and postfixed in 1% osmium tetrox-
ide in phosphate buffer (pH 7.4) for 1 hour. Then a third
fixative, 10% formaldehyde, was applied to the specimens media. This method enables us to evaluate the density and
for 1 hour and the specimens were dehydrated in increas- the organization of the collagen fibers.
ing concentrations of alcohol. After this procedure, the tis- The classification system of Watanabe et al15 was used to
sues were washed with propylene oxide and embedded in divide the discoid lateral meniscus into 3 types: complete
an epoxy–resin-containing media. Semithin sections about (full disk that covers the entire tibial plateau), incomplete
2 µm in thickness and ultrathin sections about 60 nm in (larger than normal meniscus), and the Wrisberg ligament
thickness were cut with a glass knife on an LKB Nova type (no meniscal attachments to posterior capsule or pos-
(LKB, Bromma, Sweden) ultramicrotome. Ultrathin sec- terior tibia with normal meniscal attachment to the
tions were collected on copper grids, stained with uranyl Wrisberg ligament).
acetate and lead citrate, and examined with a JEOL JEM The examination was performed on the meniscectomy
1200 EX (JEOL, Tokyo, Japan) transmission electron material. As part of the routine preoperative preparation, the
microscope. This staining procedure enhances only the col- patients signed informed consent forms enabling us to per-
lagen fibers, and the empty spaces represent the embedded form microscopic examinations on the pathologic specimens.
Vol. 35, No. 3, 2007
Figure 3. Electron micrograph showing decreased collagen
fibers (arrows) with a heterogeneous course in a patient with
an incomplete discoid meniscus (original magnification
× 20 000).
Figure 4. Electron micrograph showing decreased collagen
fibers (arrows) with a heterogeneous course in a patient with a
complete discoid meniscus (original magnification ×20 000).
Figure 5. Electron micrograph showing collagen fibers
(arrows) with a homogeneous course in the control group
(original magnification ×20 000).
Discoid Meniscus 477
Figure 6. Electron micrograph showing a few collagen fibers
(arrows) in a local area of a patient with incomplete discoid
meniscus (original magnification ×20 000).
RESULTS
Eighteen white patients participated in the study. There were
12 patients in the study group and 6 patients in the control
group. The average age of the study group and the control
group was 29 years (range, 5-50 years) and 31 years (range,
22-45 years), respectively. Four patients were found to have
complete type discoid menisci, whereas 8 patients had incom-
plete type according to the Watanabe classification. None of
our patients had Wrisberg-type discoid menisci. With respect
to type of meniscal tears observed in the discoid menisci
group, 7 patients had horizontal cleavage tear (Figure 1), 7
patients had radial tear, and 3 patients had longitudinal tear
(Figure 2). In the control group, radial tears were the most
common tear pattern and were observed in 4 patients. Also,
2 patients had longitudinal tears, 1 had a horizontal cleavage
tear, and 1 had a complex tear. None of the patients in the
control group was diagnosed with discoid menisci or had
degenerative changes.
The transmission electron microscopic examination of
the tissue samples taken from the study group revealed a
heterogeneous course in the collagen fibers in all of the
specimens (Figures 3 and 4). This course was observed in a
similar pattern in all of the specimens in both the complete
and the incomplete discoid menisci group. However, the
examination of the ultrastructure of the tissue specimens
taken from the control group demonstrated a homogeneous
course in the collagen fibers (Figure 5). Besides, the amount
of the collagen fibers was decreased in the complete and
incomplete discoid menisci groups when compared with the
control group (Figure 5). In some local areas, there were only
a few collagen fibers (Figure 6).
DISCUSSION
A discoid knee meniscus was first described more than a
century ago.16 It was shown to occur in both the medial and
lateral compartments with several different morphologic
478 Atay et al
characteristics.2,3,7 Since the first detailed examination by
Smillie12 in 1948, there has been an ongoing debate about the
exact pathologic alterations and cause of this discoid shape.
Smillie12 suggested that the discoid menisci are attributable
to the persistence of a normal fetal stage; however, anatomi-
cal studies did not demonstrate a disk-shaped fibrocartilage
during fetal development.6,9,12 Kaplan9 suggested that the
discoid shape developed secondary to the abnormal meniscal
motion attributable to lack of attachment to tibia. Regardless
of the theories that are used to explain the development of
the discoid menisci, it has been shown that discoid lateral
meniscus is associated with an increased incidence of either
lateral or medial meniscus tears, ranging between 38% and
88%.11 However, it is impractical to screen asymptomatic
patients for meniscal abnormalities; therefore, the true inci-
dence of discoid menisci and their lifetime risk of tear in the
general population remain undefined.
Arthroscopic studies have demonstrated an association
between discoid lateral menisci and meniscal tears and cys-
tic degeneration.1,11,14 Discoid meniscus tears may occur in
any of the patterns described for normal menisci, includ-
ing longitudinal, transverse, flap, and complex tears. It is
thought that the tears in discoid menisci are attributable to
abnormal shape and thickness resulting in increased stress
to the meniscal tissue.14 In addition to mechanical factors,
the number and orientation of the collagen fibers can be
important factors. In the normal menisci, there are inner
circular oriented, dense collagen fibers, which dissipate the
hoop stresses on the menisci during weightbearing. On the
outer surface, there are radially oriented superficial colla-
gen fibers, which both protect the longitudinal ones from
tearing apart and anchor them to joint capsule. Therefore,
the normal menisci have a highly organized collagen matrix
that not only provides the strong backbone to carry load but
also serves as a scaffold to hold the glycosaminoglycans nec-
essary for normal meniscus function.
It has been suggested that discoid menisci have the
same composition as normal meniscal tissue, with the only
difference being that the tissue failed to undergo complete
condensation to its physiological dimensions. However, our
findings suggest that in the discoid meniscus, the above-
mentioned organization in the normal meniscus is lost. We
demonstrated that the collagen fibers in the discoid menis-
cus are disorganized and decreased in number. This find-
ing has 2 implications. First, the discoid menisci have a
lower collagen concentration, similar to degenerated menisci,
which may increase the vulnerability of the meniscus.8
Second, the loss of organization may decrease the capacity
of the menisci to dissipate hoop stresses that arise during
normal weightbearing. This change may predispose the
menisci to tears. We believe that the loss of normal colla-
gen orientation and the decrease in the number of the col-
lagen fibers contribute to the increased incidence of tears
observed in discoid menisci.
The weakness of this study is that we could not examine
the whole meniscus, which is impractical because partial
resection is the treatment of choice in these patients.
The American Journal of Sports Medicine
Therefore, we performed our study on partial-thickness
biopsy specimens. This precludes speculating about the
architecture of the menisci. Another limitation to this
study might be that we had to use biopsy specimens from
the symptomatic menisci. Analysis of a discoid meniscus
that is free of any tear would be the ideal approach and
might demonstrate a different result; however, this is not
possible for ethical reasons. Therefore, we analyzed the
intact portions of discoid menisci that were free of any
tears and might be considered as normal.
CONCLUSION
To our knowledge, this is the first study of the ultrastruc-
ture of the discoid lateral meniscus. This study revealed
that ultrastructure of the discoid lateral meniscus signifi-
cantly differs from that of the normal meniscus. The colla-
gen fibrils are decreased in number and do not show the
normal orientation. Both of these factors may contribute to
the increased incidence of tears in discoid menisci.
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